Application Form

Care Assistant (Night)

Salary: competitive rates of pay

Contract Type: Full Time / Part Time, Permanent

Location: Rugby

Personal Details

Current Driving Licence

Are there any restrictions on you taking up employment in the UK?

Please provide evidence of your immigration status in UK e.g settled / pre-settled status or work permit.

Are you willing to work overtime and weekends if required?

Have you ever worked for or applied to this company before?


Employment History

Please complete in full, including any gaps in your employment and use the extra box at the end of the section if necessary.

Current / last employer

Previous employer 2

Previous employer 3

More employers

Employment gaps

Current Membership of Professional bodies (i.e. CIPD, NMC)

Other employment


General comments


Please provide two people from which we may obtain character and work references

Reference 1

Reference 2

Criminal record

Please note any criminal convictions except those 'spent' under the Rehabilitation of Offenders Act 1974. If none please state. In certain circumstances employment is dependent upon obtaining a satisfactory Disclosure & Barring Certificate from the Disclosure & Barring Service/Disclosure Scotland.

Data protection

  1. We are aware of our obligations under data protection legislation, including the obligation to collect only the data that is required for our specific purpose. The information collected in this application form is specific to our recruitment exercise and necessary for the performance of the role that you have applied for. If you are recruited for the role you have applied for, or any other role you are offered by us, the information provided will then be used for the purposes of your employment with us, together with further information collected upon recruitment for those purposes.
  2. We will treat all personal information about you with utmost integrity and confidentiality. Our data protection policy sets out our approach to ensuring that your data is processed in line with the data protection principles within current data protection legislation.
  3. Our privacy notice for job applicants gives you information on, amongst other things, the data we will hold about you during the recruitment exercise and what we use it for.


  1. I confirm that the information provided in this application is complete and correct and that any untrue or misleading information will give my employer the right to terminate any employment contract offered.
  2. Should we require further information and wish to contact your doctor with a view to obtaining a medical report, the law requires us to inform you of our intention and obtain your permission prior to contacting your doctor. I agree that the organisation reserves the right to require me to undergo a medical examination.
  3. I agree that should I be successful in this application, I will, if required, apply to the Disclosure & Barring Service/Disclosure Scotland for a Disclosure & Barring Certificate. I understand that should I fail to do so, or should the disclosure not be to the satisfaction of the company any offer of employment may be withdrawn or my employment terminated.